011117 DUPLICATE WARRANTS 4_REDACTED.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Wanda Childers
-4 W
Date: December 16, 2016
Re: Replacement of Lost Payroll Warrants
Please find attached 2 Affidavit/Notice of Claim(s) for lost
payroll warrants for inclusion on the next available Board agenda.
The attached item(s) have been researched to ensure that the
warrant(s) in question have not been cashed or previously re-
issued. The original warrant(s) have had a stop payment done.
Please call Wanda at ext. 60409 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant Duplicate Warrant
Thank you.
Replacement Lost Warrant Form 02/25/2015

(4-1‘41)N arhf>6
Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: lii Duplicate or U Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
Anthony E Campos (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11 /302016 / (date)(2) a warrant/check was issued to the
above named person/entity in the amount as stated below. Such warrant/check was
either never received or was subsequently inadvertently lost or destroyed and there is
no reasonable probability of its being found or presented for payment, or it was not
presented for payment within one year after the date of issuance.
Therefore, under penalty of perjury, claimant hereby affirms that this claim is correct
and the amount shown is due and owing, and the applicant requests that a replacement
warrant/check be issued to him/her in the sum of $ 135.00 .(3)
Signed: (4)
Note: Pleae !attach a Copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued
(5) Subscribed and sworn to before me this day of 20 ) (o.
oio-wzrv--1
NOTARY PUBLIC
FRANCES HANSON
My commission expires: Wary Pubric- State of Arizona
MAR1COPA COUNTY
My Commission Expires Feb. 23, 2018
Warrant/Check Number 22437251
(if known) (6)
Original Date of Issue 11/30/2016
(if known) (7)
Reason for original issue of Warrant/Check (8): (7)
It Payroll A P P. r4 V E D (11
I=1 For Services or Goods furnished D I
D Treasurer's refund/payment
ERK, BOARD Oi- SUPERVISORS
D Other: MARiCOPA COUNTY
Revised April 2015 A.R.S. 11-632 & 11-644

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or ID Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
Juanita Jackson (1), being first sworn, upon oath deposes and says:
Nan-le/Claimant
On or about November 30, 2016 (date)(2) a warrant/check was issued to the
above named person/entity in the amount as stated below. Such warrant/check was
either never received or was subsequently inadvertently lost or destroyed and there is
no reasonable probability of its being found or presented for payment, or it was not
presented for payment within one year after the date of issuance.
Therefore, under penalty of perjury, claimant hereby affirms that this claim is correct
and the amount shown is due and owing, and the applicant requests that a replacement
.(3)
Signed: (4)
NoteVPlease attac a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscribed and swor9 tc
NOTARY PUBffC
JOSEPH RODENBACK
My expires: Notary Public - Sbte of A rizoria
cornmission/ 3/ 8 My Commission MARiCOPA Exprres COUNTY Feb. 23, 2016 (seal)
Warrant/Check Number 22440668
Cif known) (6)
Original Date of Issue 1113012016
(if known) (7)
Reason for original issue of Warrant/Check (8):
*1 Payroll Es7j,
O For Services or Goods furnished 0
L 16 201
10 Treasurer's refund/payment
L I Other:
—
Revised April 2015 A.R,S. 11-632 & 11-644